Video Laryngoscopy Wins for Tracheal Intubation on the First Try

Use of video rather than direct laryngoscope led to better rates of successful tracheal intubation on the first attempt for critically ill patients in the intensive care unit (ICU) or emergency department, the randomized DEVICE trial found.

In the unblinded multicenter study, which was stopped early for efficacy at an interim analysis, the rate of success on first attempt reached 85.1% in the video laryngoscope group and 70.8% in the direct laryngoscope group (P<0.001), reported Matthew Prekker, MD, MPH, of Hennepin County Medical Center in Minneapolis, and colleagues.

"This finding may have important clinical implications because failure to intubate on the first attempt is associated with life-threatening complications, and in current clinical care worldwide, most critically ill adults undergo intubation with a direct laryngoscope rather than a video laryngoscope," the researchers wrote in the New England Journal of Medicine.

Severe complication rates during intubation, the secondary endpoint, were similar between study arms (21.4% in the video group vs 20.9% in the direct group), the team detailed.

Findings from the large U.S. trial found a benefit with video laryngoscope not seen in a smaller multicenter trial in France involving ICU patients, where the investigators reported difficulty inserting an endotracheal tube with the video approach. But Prekker and his fellow researchers pointed to two important differences between that randomized trial and DEVICE.

First, "the absence of an increased difficulty of inserting an endotracheal tube during video laryngoscopy in our trial may be explained by the consistent use of a stylet or bougie, which facilitates the insertion of an endotracheal tube into the trachea during laryngoscopy," they wrote.

Second, the use of video laryngoscopy has been increasing in recent years in the ICU and emergency department, in part due to pandemic-era recommendations that encouraged a greater distance between the patient's mouth and operator to reduce the risk of COVID transmission.

In an accompanying editorial, Yonathan Freund, MD, PhD, of Sorbonne Université in Paris, and Ben Bloom, MD, PhD, of Queen Mary University of London, said "the results of this trial are compelling and support the systematic use of video laryngoscopy in combination with appropriate training and systematic use of bougies or stylets."

But the pair noted that evidence alone does not typically bring about implementation, pointing out that it took 15 years for the adoption of ultrasonographically guided central venous catheter placement.

"There are many barriers to the implementation of new clinical interventions, including beliefs regarding the efficacy of the intervention, individual training, and the availability of equipment," said Freund and Bloom. "Successful implementation involves a behavioral approach that takes into account clinician and patient factors."

DEVICE randomized 1,417 adult patients 1:1 at seven emergency departments and 10 ICUs across the U.S. from March to November 2022. A total of 387 unique operators performed an intubation during the trial, with each performing a median of two intubations. Most (70%) were performed in the emergency department and 91.5% of patients received an intubation from an emergency medicine resident or a critical care fellow.

The primary outcome was successful tracheal intubation on the first attempt, with rates of severe complications (i.e., severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death) during intubation being a secondary outcome.

Patients had a median age of 54-55 years, and 35% were women. About 50% were non-Hispanic white, a little less than one-fourth were Black, and 14% were Hispanic. More than 27% had sepsis, and about a fourth had a traumatic injury.

The most common reasons for intubation were altered mental state in 45% and acute respiratory failure in 30%. In terms of the anticipated degree of difficulty for the procedure, 46% were considered to be moderate, 32% easy, and 9% difficult.

Among exploratory outcomes, rates of a successful intubation on the first attempt without a severe complication appeared higher in the video laryngoscope group (68.7% vs 59%). And the median duration of intubation was favorable for the video group, at 38 seconds versus 46 seconds with direct laryngoscope. The most common reason for failure on the first attempt was an inadequate view of vocal cords (3.7% vs 17.3%, respectively).

Safety outcomes, such as aspiration, injury to teeth, and esophageal intubation, were similar between the groups, with none occurring in more than 2% of the patients.

Limitations to the study, the investigators said, included that the trial was unblinded, that the vast majority (97%) of operators had performed fewer than 250 prior tracheal intubations, that the brand and shape of the video laryngoscopes were selected by operators, and that intubations in operating rooms were excluded.

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